Traditional native tissue versus mesh-augmented pelvic organ prolapse repairs: providing an accurate interpretation of current literature.

The objective of this paper was to review the literature on pelvic organ prolapse (POP) and compare the success of traditional/native tissue versus mesh-augmented repairs. A comprehensive literature review was performed using PubMed and bibliography searches to compare the anatomic success rates of native tissue (NT) and mesh-augmented (MA) prolapse repairs and to analyze outcome measures used to report success rates. Articles were included if anatomic outcomes were stated for the specific compartment of interest and included both prospective and retrospective studies. The published success rates for NT repairs versus MA repairs by anterior, posterior, or apical compartments are reported. When continence is used as the primary outcome measure, anterior NT has a success rate of 54%. Anterior NT success is as low as 30% in some studies, but generally is 88-97% when prolapse is the primary outcome particularly if apical support is included. This compares to the 87-96% success reported for anterior MA. Posterior NT success is 54-81%, which is lower than the 92-97% reported for posterior MA when prolapse is the outcome measure. The success rates for apical NT are 97-98% for uterosacral ligament suspension and 96% for sacrospinous ligament suspension, which compare favorably to sacrocolpopexy (91-100%). There are some differences in the complications reported for NT and MA. The rate of complications is approximately 8% for NT and is reported at 0-19% for MA. The higher rate for MA is largely due to mesh erosion/exposure. When similar outcome measures are compared, the published anatomic success rates of POP of anterior and apical compartmental surgery are similar for NT and MA repairs. There may be a higher rate of complications noted for mesh implantation. POP surgery is complex, and both NT and MA techniques require skills to perform proper compartmental reconstruction. An understanding of the published literature and knowledge of individual surgeon factors are important in deciding which surgical approach to use and how to best counsel patients during informed consent.

[Surgery for urogenital prolapse].

Urogenital prolapse can have a significant impact on quality of life. As the population continues to age, the prevalence of urogenital prolapse is increasing, and the lifetime risk of requiring surgery for urogenital prolapse or incontinence is now approximately 11%. The majority of women presenting with symptomatic prolapse suffer from multiple defects of pelvic support and require comprehensive repair to relieve symptoms. An understanding of normal pelvic support structures provides the basis for the anatomic approach to repair. Many appropriate options exist for surgical correction of urogenital prolapse. Procedures to reestablish apical support include culdoplasty techniques, uterosacral ligament suspension, sacrospinous suspension and colpopexy. Repair of the anterior compartment can be achieved with colporrhaphy and paravaginal repair. Posterior compartment defects are repaired with colporrhaphy, site-specific rectovaginal repair and perineorrhaphy. Most often, surgical correction of urogenital prolapse can be performed vaginally, which avoids the risks associated with laparotomy. Laparoscopic approaches for apical support and paravaginal repair may reduce the risks associated with laparotomy, but long-term follow-up data are not yet available with these techniques. The use of graft reinforcement for anterior and posterior repairs may offer improved success rates, particularly in patients with recurrent prolapse. However, further outcome studies are needed and the risks associated with the use of mesh must be considered.

Effect of amnioinfusion on the incidence of postpartum endometritis in patients undergoing cesarean delivery.

We reviewed records from 251 consecutive cesarean deliveries performed over a six-month period to evaluate the effect of amnioinfusion during labor on the incidence of postpartum endometritis in patients who delivered by cesarean section. One hundred fifty-four patients were excluded because they were not in labor, were at less than 35 weeks' gestation or received antibiotics during labor. Twenty-three of the remaining 97 patients received amnioinfusion during labor and represented the study group. Seventy-four patients did not receive amnioinfusion during labor and were used as controls. The incidence of postpartum endometritis in the amnioinfusion group was 13%, while the incidence in the group not receiving amnioinfusion was 38% (relative risk, 0.34; 95% confidence interval, 0.13-0.88; P = .026). Amnioinfusion during labor appears to significantly decrease the incidence of postpartum endometritis in patients subsequently undergoing cesarean delivery.

Stage III papillary serous cystadenocarcinoma of the ovary in a 15-year-old female.

Epithelial ovarian cancer is the most common cause of death due to gynecologic malignancies in adults, but is rare in children and adolescents. The majority of ovarian cancers in children and adolescents are stage I at diagnosis and conservative management with preservation of fertility is often possible. Twenty-nine serous epithelial cancers have been reported in females under age 20, only two of which are known to be advanced stage (both stage III). We present a case of advanced stage papillary serous cystadenocarcinoma in a 15-year-old female treated with bilateral salpingo-oophorectomy and debulking surgery followed by combination chemotherapy.

Hepatic rupture in pregnancy associated with cocaine use.

BACKGROUND: Hepatic rupture during pregnancy has a high rate of maternal and fetal mortality. Most cases occur as a complication of severe pregnancy-induced hypertension, and maternal survival has been highest in patients managed with conservative surgical therapy. CASE: A woman in late pregnancy experienced hepatic rupture associated with cocaine use. She underwent emergency cesarean delivery and was treated with topical hemostatic agents, perihepatic packing, and hepatic artery embolization. Reexploration with perihepatic packing was performed three times during the first 48 hours after delivery to control hepatic hemorrhage. Vasopressor support, blood product replacement, and prolonged assisted ventilation were used, and the patient was discharged on hospital day 42. CONCLUSION: Liver damage may result from the potent vasoconstrictor property of cocaine, leading to vasospasm and ischemia. Conservative surgical management of hepatic rupture and supportive measures resulted in maternal survival.